UPPER GASTRO INTESTINAL

TRACT BLEEDING
Dr Azrin Waheedy Ahmad
 CONTENT

• Definition
• Variceal bleeding
• Non variceal bleeding
• Risk factors
• Sign and symptoms
• Investigations
• Management
 DEFINITION OF UPPER GI BLEED

• Any source of bleeding within GI tract from oesophagus till the ligament of
Treitz
• Divided in to variceal and non variceal bleed
• Acute bleed – haematemesis + malaena
• Chronic bleed – anaemia + FOBT positive
 VARICEAL BLEEDING

• Presence of varices in the oesophagus/ fundus of stomach

• Part of the portosystemic anastomosis
• Occurs as a result of portal hypertension
• Causes of portal hypertension – extra hepatic, hepatic and post hepatic
• Assoc. with cirrhosis @ hepatitis B,C
 NON VARICEAL BLEEDING

• Mallory weiss tear

• Oesophagitis
• Oesophageal cancer
• Gastritis
• Peptic ulcer disease – gastric ulcer or duodenal ulcer
• Curling’s ulcer
• Cushing’s ulcer
• vascular malformation – dieulafoy lesion
• Gastric cancer
• Duodenal cancer
• Corrosive ingestion
• Gastric antral vascular ectasia (GAVE)
 RISK FACTORS

• Coagulopathy causes
• Liver failure
• Haematological disorder
• Smoking / alcohol
• Drugs – warfarin, aspirin, NSAIDS, steroids
• Helicobacter pylori
• Chronic renal disease – uraemia/ GAVE
• Critically ill patient (ICU) – stress ulcers
• Severe burn patient – curling ulcers
• Severe trauma/injury to CNS – cushing ulcers
• Zollinger ellison syndrome
 PRESENTATION

symptoms signs

• Upper abdominal pain • Pale conjunctiva

• Haematemesis • Cold clammy peripheries
• Malaena • Tachycardia
• Symptoms of anaemia • Weak pulse volume
• Shortness of breath • Other associated signs
• Chest pain
• syncope
 PRESENTATION

• Haemetemesis
• Vomiting of fresh blood or coffee ground vomitus
• Malaena
• Passage of black tarry stool , strong odour
• Partially digested blood
• Haematochezia
• Blood mixed with stool
• Usually lower GI in origin
• But can occur in brisk upper GI bleed
 HISTORY

• Vomiting
• amount/ content/ frequency/ duration/ wretching/ triggers
• Abdominal pain – site/ severity/ frequency/ character/ duration/ radiation/
relieving and aggravating factors
• Passsage of malaenic stool
• Symptoms of anaemia – SOB, chest pain, syncope
• Constitutional symptoms – LOA, LOW
• Dysphagia
• airway symptoms – epistaxis , chronic cough - haemoptysis
 PAST MEDICAL HISTORY

• Haematological disorder
• DM
• HPT
• IHD
• Renal disease
• Liver disease
• Previous similar episodes
• Previous surgical history
 DRUG HISTORY

• Aspirin/ antiplatelets
• NSAIDS
• Steroids
• Anticoagulants – warfarin, NOACs
 PHYSICAL EXAMINATION

• General and systemic examination

• Airway – intubation if necessary
• Breathing – give oxygen supplementation
• Circulation – HR, BP, Urine output
• Signs of shock – pale, clammy,chest pain, SOB, confusion, delirium, low
pulse volume, hypotension, tachycardia
• Signs of chronic liver disease – jaundice, ascites, hepatomegaly
• Digital rectal examination – malaenic stool. Look for any other per rectal
abnormality
 INVESTIGATIONS

• Full blood count

• Coagulation profile – INR, PT, APTT
• Renal profile
• Liver function test
• Arterial blood gas
• Group and cross match
• Main aim is to resuscitate whilst arranging for definitive management
 RESUSCITATION

• Fluid resuscitation – blood is preferable if possible

• Correction of coagulopathy – FFP, platelet
• 2 large bore iv canula
• Urinary catheter
• Oxygen supplement
• Ryles tube ?
 TREATMENT MODALITIES

• OGDS – diagnostic and therapeutic

• Mesenteric angiography with embolisation – diagnostic and therapeutic
• CTA angiogram – diagnostic only
• Angio embolisation – therapeutic
• Nuclear medicine – RBC tagged scan
• Surgery – underrunning of vessels or resection.
 ENDOSCOPIC TREATMENT

• Injection of adrenaline
• Tamponade effect and vasoconstriction
• Endoscopic clip
• Thermal – heat probe
• Argon plasma coagulation
• Clotting agents – haemoclot/ endoclot
• 2 modalities utilised
 PHARMACOLOGICAL
TREATMENT

• Proton pump inhibitor

• 80mg stat in A&E
• If high risk bleeder – IV infusion 8mg/hr for 72 hours
• If low risk – start on PPI 40mg od or BD depends on risk and address all
risk factors
 MESENTERIC ANGIOGRAPHY

• Requires contrast – care in renal patients

• Detects bleeding if rate is more than 1ml/min
 MESENTRIC ANGIOGRAM

• Requires contrast – care in renal

patients
• Detects bleeding if rate is more
than 1ml/min
 CTA ANGIOGRAM

• Needs higher rate of bleeding more than 1ml/min

• Diagnostic only
• Can help to look for rebleeding vessels to aid with angio embolisation
• Allow assessment of other vessels
 ANGIO EMBOLISATION

• Allow for therapeutic intervention

• Use of coils and foam to block the feeding vessel
• May lead to ischaemia
• Migration of coils – embolisation of other organs
• Perforation
• Dissection
 SURGERY

• Traditionally prior to PPI

• Vagotomy were done
• After PPI, no vagotomy performed – reduced rate of ulcer
• Surgery for failed endoscopic therapy/ complicated
• Nowadays, bleeding peptic ulcers treated by underrunning of ulcers
• Partial gastrectomy in extreme cases
 VARICEAL BLEEDING

• Bleeding varices can be catastrophic

• Need time for OGDS
• Temporary measures
• Sengstaken blakemore or minnessota tube
DISCUSSION